Dr. RAMESH K. SHELAT

for the use only of a registered medical practitioner or a hospital or a laboratory.

VALUE OF HERBAL DRUGS

IN FUNCTIONAL UTERINE BLEEDING

By

Dr. RAMESH K. SHELAT, M.D. F.R.C.S. (Ed).,

Consulting Obstetrician and Gynaecologist, Associate Surgeon, Surat General Hospital,

Hon. Obst. and Gynec., Lakhpati and Kadiwala Hospital, Surat

and

Dr. (Miss) USHA N. SHAH B.A., M.S.,

1· Lakhpati Maternity Hospital, Surat. 

The Indian Practltlon, P.P.: 697: 702 October 1966

         VALUE OF HERBAL DRUGS

IN FUNCTIONAL UTERINE BLEEDING

By

Dr. RAMESH K. SHELAT, M.D. F.R.C.S. (Ed).,

Consulting Obstetrician and Gynaecologist, Associate Surgeon Surat General Hospital,

     Hon. Obst. and Gynec., Lakhpati and Kadiwala Hospital Surat

and

Dr. (Miss) USHA N. SHAH B.A. M.S.,

 2.Lakhpati Maternity Hospital, Surat.

 

INTRODUCTION

UTERINE bleeding other than normal menstrual flow or an increased and or pro­ longed menstrual flow with or without a change in the cycle is a commonly encountered entity in gen­ real as well as consulting practice and hospital out-doors. The mechanism causing it is not known precisely except that it is caused by distur­ balances of the physiological mechanism that con­ trolls menstrual cycle. As such, treatment still remains empirical and rather unsatisfactory. Treatment is aimed at the control of excessive bleeding and restoration of the normal menstrual cycle in pre-menopausal age groups.

In some cases, the cause may be apparent but there are cases where exhaustive investi­actions are necessary to detect the cause of bleeding e.g. in suspected uterine and ovarian malignancy. However, even with careful exami­ nation of the pelvis and diagnostic curettage in a number of cases, no definite cause is found. And it is a common clinical experience that in the same cases routine hormone treatment and surgical measures like D & C do not help and hysterectomy has to be resorted to as a last measure.

PRESENT STUDY –

Anys treatment that can help to avoid drastic drug or surgical measures in established cases of functional uterine bleeding is therefore wel­ come and

this study was undertaken to assess the value of a combination of herbal drugs repu­ted in Ayurveda in the management of uterine bleeding

PHARMACOLOGY  AND   THERAPEUTICS OF THE DRUG

Tablet  Ayapon  (Alarsin) was tried in this study.

Each tablet of Ayapon contains:,

Ayapana (Eupatorium Ayapana)         :          130 mg.

Nagkeshar (Mesua ferrea)                  :           32 mg.

Ashoka (Saraca indica)                       :           130 mg.

Godanti (Gypsum)                               :            32 mg.

Ayapan : Contains non-toxic haemostatics ayapin and ayapanin. It is used in uterine bleed­ ing and other  haemorrhages.

Nagkeshar: is astringent and haemostatic. It decreases actual bleeding and is therefore use­ful during active bleeding.

Ashoka: is astringent and uterine sedative. It has a direct action on uterine mucosa and is used in menorrhagia and postpartum haemor­ changes.

Godanti: Is astringent and cooling and haemostatic. Supplies calcium in an assimilable form

MATERIALS AND METHOD –

Only established cases of functional uterine bleeding where no pathological or other cause could be detected, were selected from our con­sulting practice and hospital patients. All of them had been previously treated on usual lines: hormones, ergot preparations, and surgi­ cal measures like D & C but either had not benefited or had a recurrence of bleeding.

Most of these consisted of cases of uterine bleeding persisting after abortion, myomec­tomy, manual removal of placenta and evacuainthistion of retained products of conception and uterine bleeding during puerperium. And a few resistant cases of menorrhagia, metrorrhagia polymenorrhoea, and cases of persisting bleeding after l.U.C.D.

Dose: 2 tablets Ayapon 3 times a day for 2 to 12 weeks. In those cases which benefited, 1-2 tab. b.d. or t.d.s. for one week starting 3 days prior to expected menses, were given for next .three cycles.

As a supportive treatment, haematinics and multivitamins were given where found neces­ sary. Bed rest was advised during bleeding episodes. Superficial psychotherapy – explanations and reassurance was given in all cases and particularly their fear of cancer was allayed.

RESULTS –

Results were evaluated according to de­ crease in duration and quantity of bleeding and were classified as good, moderate, slight and nil when there was no improvement. Table I

Results in F.U.B. after 1.U.C.D. 

F.U.B.	No. of cases	Good	Moderate	Slight	Nil
After Loop	20	18
After G. B. ring	5	4

In this group of cases usual drugs were used without any benefit. In most of these cases   bleeding was controlled within  7-10 days  and Ayapon  was  continue2 t.d.s. for one month.

Table II 

Results according to a type of bleeding 

Symptoms	No. of cases	Good	Moderate	Slight	Nil
Post-abortion bleeding	10	7	2
Puerperal   bleeding	20	16	3
Bleeding after  myomectomy	4	2	2
Bleeding after manual removing of
placenta and evacuation of retained products of conception	12	9	2
Menorrhagia	10	7	2
Metrorrhagia	5	3		1
Polymenorrhoea	5	2		2
Total	66	46	12	6	2

CASE REPORTS

1. 16 old unmarried girl. MH – 6-8/20-25 days. LMP: 8 days back ; profuse bleeding at short intervals for 6 months. Ayapon : 2 tds/1 mth., 1 tds/1 mth. Result: good, Periods reg­ ular.
2. 32 old 4 FTND, 3 living. MH/lrregular 6-8/ 15-30 days. LMP: 10 days back. Profuse ir­ regular bleeding for one year following nor­ mal delivery. Pelvic findings: normal. Ayalon : 2 tds/2 months. 1 tds/1 month, Re­ sult: Good, period regular, bleeding control­ led.
3. 35 old; 7 para, 1st abortion, 4 FTND, last two abortions at 4th and 3rd months. MH: 8- 10/28-30 days. Regular but profuse period following last abortion 1 year back. D & C done 6 months back. Pelvic finding : normal. Ayapon 2 tds/2 months, 1 tds/ 1 mth. Results: Flow normal.
4. 18 odl unmarried girl: MH: 6-8/15-20 days. Profuse period at short intervals for past 8 months. Ayapon: 2 tds/.1 mth; 1 tds/2 mths. Result: Good, periods regular .
5. 30 Ys. Primarysterility. MH : 6-8/20-30 days. LMP : 4 days back. Pessary for R. V. Ut and D & C for sterility done. Profuse, irregu­ lar periods & dysmenorrhoea since pessary treatment 8 mths back. Pelvic findings : nor­ mal. Ayapon : 2 tds/2 mths.; 1 tds/1 mth. Re-suit: Good, periods regular.
6. 31 Ys. Secondary sterility : 1 FTND, 8 yrs. back, living. MH: 8-10/15-30 days, previ­ ous history of menorrhagia.Treated with hor­ mones, and D & C. was done. Irregular, pro­ fuse periods following D & C. Pelvic findings : normal, Ayapon :2 tds/1 mth; 1tds/2 months. Result : Good.
7. 22 old. 1 FTND. 1 yr. back, living, MH: 6- 8/ 15-30 days ; irregular period for past 6 months. Pelvic findings: normal, Ayapon : 2 tds/2 months; 1 tds/1 mth. Result: Good.
8. 16 old, unmarried, MH: FMP-1 yr. back; 8-10/ 15-20 days; LMP-15 days back. Con­ tinuous bleeding for 2 months. Treated with hormones with temporary benefit. Ayapon 2 tds/2 mths; 1 tds/1 mth. Result: Good, periods regular .

OBSERVATIONS

1. In those cases which benefited, bleeding was controlled within 3-7
2. In metrorrhagia, there was remarkable im­ improvement in the regularity of
3. Even in resistant cases where previous ex­ tensive hormone treatment and D & C were done there was remarkable In such cases the drug was continued for 3 months (2 tab. t.d.s.).
4. Where local pathology such as congestion was treated surgically but bleeding per­ sisted, Ayapon proved
5. Toxicity or side-effects were not There was no withdrawal bleeding after Ayapon treatment was discontinued.
6. For full benefit, Ayapon treatment should be continued for 2-3 months even after bleeding is
7. Its simple and safe dosage is helpful for pro­ longed treatment which is necessary in resistant cases of functional uterine bleedings.

DISCUSSION AND CONCLUSIONS –

In cases where the family and the patient allow, the family physician should not hesitate to examine the case per vaginum rather than treat the case blindly for a considerable time. The only things necessary for examination are bi-vulva speculum and a pair of gloves. The examination should be in the presence of an at­ tenant or a relative. The aim should be to rule out organic disease especially carcinoma. This helps the family physician to direct many an early case of genital malignancy. Cancer is cur­ able provided it is diagnosed and treated in the early stages. Speculum examination will reveal any obvious cause of bleeding from vulva, vag­ ina and vaginal part of the cervix. The urethra should also be examined as a possible site of bleeding.

In a considerable number of cases, it is prob­ able that psychological disturbances are the principal causes of functional uterine bleeding, particularly during the prime reproductive years. Most of these factors are related to sex­ual or reproductive functions, fear of pregnancy etc. In most of such cases superficial psycho­ therapy – explanations, reassurance, ventila­ tion of grievances – is a must. But in refractory cases, deep psychotherapy is necessary and such cases should be referred to a psychiatrist.

In reproductive age group before 40 years hysterectomy and other drastic surgical mea­ sures and drastic drug therapy should be av­oided if there is no specific use for them. Indis­ criminate use of hormones should be controlled. Oestrogens can be employed only as short term therapy. They · arrest the metropathic bleeding but the subsequent withdrawal bleed­ ing is sometimes profuse. There are also toxic effects as nausea and vomiting.

Malignancy and organic diseases should be ruled out in older group of patients by physical examination, vaginal smears, and endometrial and cervical biopsies before embarking on sur­gical and or drug treatment. Surgery can now be reserved for refractory cases and for those nearing or past their reproductive period. Very profuse bleeding may require an emergency D  & C both to establish the exact diagnosis and to control the bleeding. Ergot preparations are useless. Injections of calcium, vitamins C., K. and P. as also specific haemostatics such as carbazochrome, spinal cord extracts, etc., all of which are very widely used, have their useful­ ness in bleedings from tumours, infections and trauma as supplementary measures. But in functional uterine bleeding, in some cases hor­ mones or D & C help to some extent but not al­ ways. Once bleeding is controlled either by a surgical and or medical curettage cyclical hor­ mone therapy is adopted.

Against this background of unsatisfactory treatment, the value of this herbal combination de­ serves attention. Phadnis (1964) had observed its usefulness in menorrhagia of long-standing treated with hormones, etc. and where D & C was done. And in some of these cases Ayapon helped to avoid hysterectomy. In a controlled series, Mehta (1964) found it efficacious in menorrhagia and metrorrhagia. Pandya et al (1963) have reported comparatively better re­sults with a combination of Ashoka and Nag­ keshar – two ingredients of Ayapon – in menor­ rhagia. Javeri (1965) had tried Ayapon from puberty to menopausal age groups with en­ couraging results. Her cases included .func­tional uterine bleedings after surgical measures like D & C, Caesarean sections and G.B. ring, etc.

Our observations tend to show the useful­ ness of Ayapon in functional uterine bleedings persisting after abortion, myomectomy, manual removal of placenta and evacuation of retained products of conception and uterine bleeding during puerperium. And in a few resistant cases of menorrhagia, it helped in avoiding drastic surgical measures like hysterectomy.

With the introduction of  Loop on a  mass scale, Loop bleeding cases are being reported and in these cases drastic drug or surgical treatment is out of the question. Ayapon seems to be a drug of choice in these cases because it is safe and economical.

It is likely to be useful as a supportive therapy where surgical measures have to be adopted. In resistant eases this drug has to be continued for about 3 months for complete relief. No close observation for adjustment of dosage are necessary and it has no toxicity or side-effects.  These are advantages for a family physician who has to treat a number of these cases in daily practice.

ACKNOWLEDGEMENT-

We are thankful for M/s. Alarsin Pharmaceut­icals, Bombay-1, for the liberal supply of Ayapon tablets.

REFERENCES

1. Ghosh R.:  Pharmacology,  Materia Medica during puerperium. And in a few resistant cases and Therapeutics, 20th  Edition,  Hilton    Calcutta, 1957.
2. Javeri Veenaben: Treatment of Functional  Uterine Bleeding (A Clinical study with Ayapon), Indian Practitioner, 18:2,  783,1965.
3. Mehta A. M.: Use of a Eupatorium Ayapon Combination in Functional Uterine Bleeding, paper before the Scientific Session of 40th All India Medical Conference at Kakinada, 1964.
4. Pandya S. C. et  al:  Value  of  Indigenous Drugs in Menorrhagia; Current Medical Practice 7:8, 543, 1963.
5. Phadnis H. N.: Use of Ayapon Compound in Functional Uterine Haemorrhages; Antisep­ tic , 61: 10, 683, 1964.